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Agenda: Healthcare Safety Investigations Conference 2021

Just under a week to go to our biggest Healthcare Safety Investigations Conference yet.
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HSIB places emphasis on effective system design and standardisation of practice to tackle common never event

The Healthcare Safety Investigation Branch (HSIB) has today published its latest report,highlighting why current measures aren’t effective in preventing the insertion of an incorrect intraocular lens…
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HSIB release interim bulletin relating to ectopic pregnancy investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into the diagnosis of ectopic pregnancy.
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Notification of investigation: high risk medicines administration in hospital to frail older people

The Healthcare Safety Investigation Branch has launched an investigation into an incident where a hospital inpatient was administered repeated doses of warfarin in error and suffered significant harm…
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Notification of investigation: the diagnosis and management of ectopic pregnancy

Following an initial investigation into the care of a patient who had a ruptured fallopian tube following a delay in diagnosis of an ectopic pregnancy, the Healthcare Safety Investigation Branch (HSI…
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Notification of investigation: management of chronic health conditions in prisons

The HSIB has launched an investigation regarding the management of chronic health conditions in prisons.
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Notification of investigation: EPMA systems and safe discharge

The Healthcare Safety Investigation Branch has launched an investigation into an incident where a patient was inadvertently prescribed and administering two anticoagulation medications.  This occurre…
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HSIB release interim bulletin relating to button battery investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into Button Battery Ingestion.
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HSIB release interim bulletin relating to radiological findings investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into the communication and follow-up of unexpected significant radiological findings.
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HSIB publishes latest report - administering a wrong site nerve block

The Healthcare Safety Investigation Branch (HSIB) has today published an investigation report relating to a never event, the administering of a wrong site nerve block. 
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Notification of investigation: communication and follow up of significant unexpected radiological findings

The Healthcare Safety Investigation Branch (HSIB) has launched a full investigation into a case where a patient’s chest x-ray, showing a possible lung cancer, was not acted upon.
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HSIB publish annual review

The Healthcare Safety Investigation Branch (HSIB) has today published its annual review.  Focusing on HSIB’s role in shaping a safer healthcare system, the review charts HSIB’s progress over the past…
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HSIB release interim bulletin relating to testicular torsion investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the management of early onset testicular pain.
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Notification of investigation: ingestion of button batteries in children

The Healthcare Safety Investigation Branch has launched an investigation following a referral regarding a child who died following an unknown and undetected ingestion of a button battery.
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HSIB second national investigation report: CAMHS to AMHS

Today, the Healthcare Safety Investigation Branch has published its second full investigation report to support a new learning culture around mistakes in the NHS.
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Notification of investigation: primary management of acute onset testicular pain

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation following a referral regarding a patient who suffered the loss of a testicle after a missed testicular torsion.
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Chief Investigator's statement - wrong prosthesis report

This first report is the culmination of many months of rigorous and independent investigation, working closely with those involved in the incident, as well as relevant organisations and subject matte…
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HSIB report reinforces national approach to tackle preventable deaths from deterioration

Our latest report, published 23 May 2019, recommends tackling the recognition and response to deteriorating patients with the same national approach driving improvement in identifying and treating se…
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HSIB release interim bulletin relating to wrong lens investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the insertion of an incorrect intraocular lens.
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HSIB release bulletin relating to CAMHS to AMHS investigation

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to the full investigation into the transition from Child and Adolescent Mental Health Services (CAMHS) to A…
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HSIB release bulletin relating to mental health care in emergency departments

The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the provision of mental health care to adults in the emergency department.
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Notification of investigation: Design and safe use of portable oxygen systems

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The c…
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Notification of Investigation: Implantation of the wrong prosthesis

The Healthcare Safety Investigation Branch (HSIB) is launching a full investigation into a case involving a patient who had a wrong prosthesis implanted during a total hip replacement operation.
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Notification of Investigation: Insertion of incorrect intraocular lens

The Healthcare Safety Investigation Branch (HSIB) was made aware of a patient who had the incorrect strength intraocular lens implanted during cataract surgery.
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HSIB release details of investigations in an acute care setting

The Healthcare Safety Investigation Branch (HSIB) has released two interim bulletins charting the progress of investigations focusing on patient safety within an acute care setting.
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Notification of Investigation: Wrong route administration of an oral drug into a vein

The Healthcare Safety Investigation Branch (HSIB) was made aware of a child who was inadvertently given oral liquid medication intravenously during an elective procedure.
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Notification of Investigation: Transition from Child and Adolescent Mental Health Services to Adult Mental Health Services

The Healthcare Safety Investigation Branch (HSIB) was made aware of an 18-year-old man who, shortly after transferring from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health …
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AvMA Chief Exec visits HSIB

Last Thursday (5 October), Peter Walsh, Chief Executive of AvMA (Action against Medical Accidents) visited HSIB to deliver an insightful talk, focusing on AvMA’s work supporting patients and families…
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Notification of Investigation: Provision of mental health services in emergency departments

The Healthcare Safety Investigation Branch (HSIB) was made aware of a woman who, having presented to her general practitioner, ambulance service and the emergency department of her local hospital, su…
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HSIB shares learning internationally at New Zealand safety symposium

In this short video, HSIB national investigator Saskia Fursland talks about her keynote speech at the Human Factors in Healthcare Symposium in New Zealand.
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Notification of Investigation - Wrong site interventions

The Healthcare Safety Investigation Branch (HSIB) were notified by an Acute Trust of an incident that took place in June 2017 relating to a wrong site intervention.
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